The Role of the Gastroenterologist in an Integrated Nutrition Pathway for Acute Care

Transcription

1 The Role of the Gastroenterologist in an Integrated Nutrition Pathway for Acute Care A Case Based Discussion Khursheed Jeejeebhoy MD PhD Leah Gramlich MD

2 Conflict of Interest Dr. K. Jeejeebhoy Abbott Canada Speakers Bureau Baxter Canada Speakers Bureau Shire Consultant, Research Support Dr. Leah Gramlich Abbott Canada Speakers Bureau Baxter Canada Speakers Bureau Shire Consultant

3 Learning Objectives Describe an approach to Integrating Nutrition Care in hospitalized patients (INPAC) Detail strategies to address nutrition care in Well nourished Risk for Malnutrition Severely Malnourished Discuss the role of the gastroenterologist Describe the expected outcomes of nutrition care in heterogeneous populations

4 Nutritional State Nutrient Intake (-) (+) Metabolic Stress Critical State (+) Gastrointestinal Disease

5 Nutrition in Medical Care Subjective Global Assessment (SGA) Beside clinical evaluation Composite assessment of factors influencing Nutritional Status Nutrient intake Gastrointestinal function Disease effect on metabolic requirements Evaluates Severity of the effects of these factors Trajectory and persistence of weight loss Reduction of function Reproducible and identifies patients who benefit from Nutritional Therapy

6 The German Hospital Malnutrition Study. Pirlich et al. Clinical Nutrition 2006 SGA in 1886 consecutive admissions 1073 in 7 University Hospitals 813 in 6 Community Hospitals

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8 SUBJECTIVEGLOBAL ASSESSMENT (MD, RD) SGA A Well Nourished No weight loss or deficit in nutrient intake No gastrointestinal symptoms impacting nutrition Normal functional status Normal subcutaneous fat and muscle mass Improving findings of malnutrition. SGA B Moderately Malnourished 5 10 % weight loss in the past 6 months. Definite decrease in oral intake. Gastrointestinal symptoms impacting nutrition. Moderate functional deficit or recent decline. Mild to moderate subcutaneous fat and muscle mass loss on physical examination SGA C Severely Malnourished > 10 % weight loss in the past 6 months. Severe decrease in oral intake; Gastrointestinal symptoms impacting nutrition Severe functional deficit. Severe deficit of subcutaneous fat and muscle loss on physical examination

9 Nutritional Assessment: Subjective Global Assessment SGA A: Well Nourished SGA B: At risk for malnutrition SGA C: Severely Malnourished

10 Nutritional assessment: comparison of clinical assessment and objective variables for the prediction of length of hospital stay and readmission Khursheed N Jeejeebhoy, Heather Keller, Leah Gramlich, Johane P Allard, Manon Laporte, Donald R Duerksen, Helene Payette, Paule Bernier, Elisabeth Vesnaver, Bridget Davidson, Anastasia Teterina, and Wendy Lou AJCN 2015

11 Three month intervention with protein and energy rich supplements improve muscle function and quality of life in malnourished patients with non neoplastic gastrointestinal disease A randomized controlled trial Norman et al. Clinical Nutrition 2008, 27;48 56

12 Refeeding SGA B+C Patients with GI Disease Norman Clin Nutr 2008

13 Figure 4. Change of the SF 36 scales role physical and general health during the study period. Data presented as box plot. The box plots display the minimum, the maximum and the 25th, 50th and 75th percentiles. Kristina Norman, Henriette Kirchner, Manuela Freudenreich, Johann Ockenga, Herbert Lochs, Matthias Pirlich Three month intervention with protein and energy rich supplements improve muscle function and quality of life in malnourished patients with non-neoplastic gastrointestinal disease A randomized controlled trial Clinical Nutrition, Volume 27, Issue 1, 2008,

14 The Integrated Nutrition Pathway for Acute Care (INPAC): Building consensus with a modified Delphi Keller et al Nutrition Journal 2015

15 Mrs. JS: 42 yo female CC: abdominal pain HPI: RUQ pain off and on for 6 months associated with nausea, early satiety No weight change No reduction in oral intake

16 Patients NOT at risk of malnutrition This is a minimum Standard Nutrition Care provided to ALL patients. This Standard Nutrition Care promotes food intake and monitoring of the patient so that challenges to food consumption can be identified readily and treated.

17 Mrs. JS Consider the Role of the Gastroenterologist in Nutrition Care PMH Diabetes, HTN, Dyslipidemia Ht 166 cm Wt 100 kg BMI 36 P/E no features of lean tissue or fat loss Labs: Alk Phos 379, AST 502, Bili 48 TG 1.8 Glu 12 WBC 12 HCT 39 Lipase 230 U/S: fatty liver, cholelithiasis, CBD=12 mm CT: mild acute pancreatitis

18 Level A: Standard Nutrition Care Nutrition Care is Everyone s responsibility MM MD Natural history of presenting illness? Need/rationale for NPO? Pain and Symptom Control? Impact of Investigations? Impact of Treatment?

19 Mrs. JS Consider the Role of the Gastroenterologist in Nutrition Care Do you feed this patient? Are there any restrictions? What strategies and symptoms would you focus on in order to enhance oral intake? Metabolic Syndrome and NAFLD What is your role during this admission?

20 Mr. DC: 66 yo male CC: Crohns disease, 3 previous resections increasing symptoms despite Remicade with adequate trough levels HPI: 6 months worsening symptoms including abdo pain, reduced bowel movements Weigh loss: UBW=80 kg, Ht=175cm CBW=73kg BMI = 24.8 Oral intake reduced for 3 weeks

21 Continue Level A: Standard Care AND provide more nutrient dense food to patients at meals and between meals to optimize oral intake. Patients at SGA B or Level A with <50% food intake MD: Natural History of Disease? Need/rationale for NPO? Pain and Symptom Control? Impact of Investigations? Impact of Treatment? Short term and Long term impact of disease?

22 Nutrition Care is Everyone s Responsibility!

23 Mr. DC Consider the Role of the Gastroenterologist in Nutrition Care P/E subtle features of lean tissue and fat loss CT abdomen: incomplete SBO with thickening of neoterminal ileum Endoscopy: neo TI 8mm CTE: no fistulae; 2 cm stricture at ileocolic anastamosis Labs: WBC=9 Hbg=102 (N/N, increased RDW) pre alb = (N= ) B12=148 Monitored Oral Intake texture modified dietary intake (full fluids); consuming 2 ONS/d plus 500 cc of clear fluids Fasted 4/7 days since admission

24 What do you need to do to support Mr.DC? Consider the Role of the Gastroenterologist in Nutrition Care?consult the dietitian? Ensure patient is not NPO? Treat Crohns disease? What is the role of IV Fluid? Initiate non volitional feeding? EN/PN Ask: What is the goal/impact of my IBD therapy? What is the goal of my nutrition therapy? Short term? Long term? The role of the gastroenterologist includes diagnosing and treating underlying disease and prioritizing and implementing a Nutrition care plan in those at risk!

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26 Figure 3. Change in hand-grip strength per AMA increase is significantly greater in ONS patients than in DC patients. Data given as mean and STD. Kristina Norman, Henriette Kirchner, Manuela Freudenreich, Johann Ockenga, Herbert Lochs, Matthias Pirlich Three month intervention with protein and energy rich supplements improve muscle function and quality of life in malnourished patients with non-neoplastic gastrointestinal disease A randomized controlled trial Clinical Nutrition, Volume 27, Issue 1, 2008,

27 Mr. NJ: 72 yo male CC: Dysphagia HPI: 3 months progressive difficulty swallowing Weight loss: UBW=100kg, Ht=180cm CBW=82kg BMI=25.3 Reduction in oral intake over 3 weeks able to take only soft solids and liquids

28 A comprehensive dietitian assessment is the basis for Level C: Specialized Nutrition Care. This should occur within 24 hours of completion of the SGA or after 3 days of low food intake for those originally designated as Level B. Patients at SGA C or Level B with <50% food intake after 3days MD: Natural History of Disease? Need/rationale for NPO? Pain and Symptom Control? Impact of Investigations? Impact of Treatment? Short term and Long term impact of disease? Goals of Care?

29 Mr. NJ Consider the Role of the Gastroenterologist in Nutrition Care P/E Loss of fat and lean tissue Endoscopy obstructing esophageal cancer CT chest/abdomen crurallymphadenopathy Labs: WBC=6 Hbg=122 Albumin=29?Grip Strength NPO 3 days for tests; able to swallow 500 ml/d Consultation with oncology, surgery 6 8 days post admit

30 Nutrition Care is Everyone s Responsibility!

31 Mr. NJ Consider the Role of the Gastroenterologist in Nutrition Care How high on your priority list is nutrition? What are your therapeutic options: EN, PN, Stent, ONS? When do you initiate nutrition care? How do you define goals for feeding and nutrition?

32 From: Nutritional Support and Outcomes in Malnourished Medical Inpatients: A Systematic Review and Metaanalysis JAMA Intern Med. 2016;176(1): doi: /jamainternmed Outcomes: No impact on mortality No impact on admission Reduce readmission Increased weight?is this really no effect? Figure Legend: Study Flow DiagramICU indicates intensive care unit. Date of download: 2/17/2016 Copyright 2016 American Medical Association. All rights reserved.

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34 Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial Nicolaas E. Deutz a, *, Eric M. Matheson b, Laura E. Matarese c, Menghua Luo d, Geraldine E. Baggs d, Jeffrey L. Nelson d, Refaat A. Hegazi d, Kelly A. Tappenden e, Thomas R. Ziegler f, on behalf of the NOURISH Study Group

35 NOURISH Deutz et al Clinical Nutrition 2015

36 NOURISH Deutz et al Clinical Nutrition 2015

37 From: Nutritional Support and Outcomes in Malnourished Medical Inpatients: A Systematic Review and Metaanalysis JAMA Intern Med. 2016;176(1): doi: /jamainternmed Nutrition Intervention vs Control: Mortality Figure Legend: Forest Plot Comparing Nutritional Intervention vs Control for MortalityM-H indicates Mantel-Haenszel. Date of download: 2/17/2016 Copyright 2016 American Medical Association. All rights reserved.

38 From: Nutritional Support and Outcomes in Malnourished Medical Inpatients: A Systematic Review and Metaanalysis JAMA Intern Med. 2016;176(1): doi: /jamainternmed Nutrition Intervention vs Control: non elective admissions: Figure Legend: Forest Plot Comparing Nutritional Intervention vs Control for Nonelective ReadmissionsM-H indicates Mantel-Haenszel. a Calculated and approximated from readmission rate. b Calculated and approximated from readmission frequency. Date of download: 2/17/2016 Copyright 2016 American Medical Association. All rights reserved.

39 From: Nutritional Support and Outcomes in Malnourished Medical Inpatients: A Systematic Review and Metaanalysis JAMA Intern Med. 2016;176(1): doi: /jamainternmed Table Title: Outcomes Overall and in Subgroups Date of download: 2/17/2016 Copyright 2016 American Medical Association. All rights reserved.

40 Perioperative Parenteral Nutrition 429 patients enrolled All operative patients eligible Nutrition index or SGA used to classify malnutrition Randomized to control or TPN Energy = RMR kcal Protein = 150 kcal/g N Buzby et al. 1991

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42 Conclusions Nutrition care is everyone s responsibility The greater the nutrition risk, the greater the role of the gastroenterologist in defining and supporting nutrition care Nutrition care must span the continuum from hospital to home Do not delay nutrition care in those at high risk for the sake of diagnosis and or treatment Nutrition care presents an opportunity to engage patients in their own care